A coroner said there were a series of lost opportunities to correctly diagnose a woman who died of a burst aneuryism in her aorta at Bradford Royal Infirmary while waiting for a CT scan.
Assistant Bradford Coroner Dr Dominic Bell said yesterday there were a number of “sequential omissions” and “errors of professional judgement” rather than a failure of care made before 67-year-old Lilly Russell’s death on June 25, 2012.
Although the likely outcome would have been one of death even if she had been dignosed in A&E, Dr Bell said Mrs Russell was still “denied the opportunity of a successful outcome” which would have involved managing her blood pressure.
Two days before she died, Mrs Russell, of Woodend Court, West Bowling, had taken herself to A&E with worsened chest pains after an incident lifting a patient at the nursing home where she worked.
Doctors admitted her to a medical assessment ward after "a bizarre-looking" chest X-ray came back showing up suspected cancer. In reality, it was an aneurysm in her aorta which burst, killing her suddenly before she got the planned CT that had been down-graded to wait until after the weekend.
Making a narrative conclusion, Dr Bell said from the point of Mrs Russell's hospital admission, there was a series of events and opportunities at the point of medical review which should have prompted reconsideration of the diagnosis and triggered earlier investigation with CT scanning.
"On a balance of probability, however, even if the diagnosis had been derived at some earlier point in time and an appropriate management strategy activated, Mrs Russell would have been unlikely to survive the remedial operative intervention that would have been necessary," he said